Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Monday, January 22, 2007

In a study that parallels an earlier study (and accompanying post – Lexapro for Life), Dr. Martin Keller (presumably a primary investigator on this study) found that long-term venlafaxine (Effexor) use reduces risk for depression.In fact, he said,

these data showed that venlafaxine extended release can help prevent new episodes of depression -- providing an option to the millions of adult patients with depression who have experienced a disappointing setback or who are still seeking symptom relief.

Please note that I have text of a document from PR Newswire indicating that he made the above statement, but I don’t have a link to the text.

His comments are not all that different than those of Dr. Susan Kornstein, who was quoted as saying the following about the long-term effects of Lexapro:

These findings indicate the importance of maintenance therapy for patients with recurrent major depressive disorder beyond four to six months of improvement, even if a patient’s depressive symptoms appear to be resolved

This study: The Effexor results have not been published to my knowledge, but from what I gather from the study description, this study examined people who were on Effexor and received some sort of therapeutic response while taking it.Then, some of them kept taking Effexor and some were assigned to take a placebo (of course, not knowing they were switched to placebo).Those who took Effexor were significantly less likely to experience a recurrence of their depressive symptoms compared to those on placebo.So, apparently, you should be on Effexor forever.As noted above, Keller (and in a similar study, Kornstein) say this means that you should stay on your meds long-term because they prevent depression.

Withdrawal from Effexor: Just like Kornstein, Keller has absolutely misinterpreted the evidence.For example, in one small study, discontinuation of venlafaxine was associated with adverse events in 78% of patients compared to 22% of patients who stopped taking a placebo.Another, larger study found, similarly, that Effexor was related to increased rates of discontinuation symptoms compared to placebo.There are frequent reports to a national medication hotline in the UK regarding discontinuation symptoms when patients stop taking Effexor.In addition, there are also case reports of experiencing shock-like sensations during venlafaxine withdrawal.For a brief read on these shock-like sensations, check out this brief read in the British Medical Journal.In addition, it is now known that for paroxetine (Paxil), another antidepressant, healthy (not depressed) volunteers at times experienced depression upon ceasing taking their medication.Given the similar mechanism of action between Effexor and Paxil, one would expect a similar result for Effexor.

A quote from Dr. David Healy helps to summarize this fundamental manipulation of evidence by drug companies (and their allied “independent” academics):

It is clear now that the companies must have known that a certain proportion of these patients re-randomised to placebo, who subsequently complained of depressive and anxiety symptoms, will have been suffering from withdrawal problems. These withdrawal problems however appear to have been used as a basis for claiming that continued SSRI intake had a prophylactic effect against nervous and depressive problems. Based on such studies companies sought and have received licences to make these claims regarding prophylaxis.

In other words, because SSRIs and similar drugs (e.g., Effexor) have withdrawal symptoms that sometimes lead to depression, it looks like they are effective in preventing depression because people often get worse shortly after stopping their medication.The drug companies (Wyeth, in the case of Effexor) would like you to believe that this means antidepressants protect you from re-experiencing depression once you get better, that they are a good long-term treatment.A more accurate statement is that antidepressants protect you from their own substantial withdrawal symptoms until you stop taking them.

See No Withdrawal, Mention No Withdrawal: I do not say this as a personal affront to Keller, Kornstein, or any other academic who has made public statements regarding the long-term efficacy of antidepressants, but it seems odd that anyone, particularly anyone with research credentials, could ignore the solid evidence that there are substantial withdrawal symptoms associated with antidepressants.Many researchers apparently continue to toe the line of the drug companies that “it’s the depression, not the drug” that causes depression to return.

The Current Verdict on Long-Term Outcomes: Depression is indeed a nasty condition that often returns after it is successfully treated or after it just vanishes due to the passage of time.So yes, we should treat it.However, let’s keep in mind that antidepressants are barely more effective than a placebo in the short-term and, as we see here, can lead to problems in the long-term, where one can either choose to stay, for years, on an antidepressant (perhaps indefinitely) or have a good chance of risking some heinous withdrawal effects.Psychotherapy is much better in the long-run for depression, but it still does not positively impact many people.Like it or not, psychotherapy for depression has the best (though limited) success rate, perhaps due solely to its lack of causing withdrawal effects, or at least causing them at a much lower rate than meds.

14 comments:

Sara
said...

Can you even believe that these doctors don't understand the difference between rebound from drug withdrawal and relapse to an underlying condition? It boggles the mind that they could have been prescribing antidepressants for years and not understand the phenomenon of chemical dependency. Have the drug companies really been doing such a great job of brainwashing or is it just these guys are so desperate to have confirmation of the biological model for mood disorders that they can't see what is staring them right in the face? The BBC produced a documentary on Paxil called The Secrets of Seroxat and in it a doctor is interviewed and describes how convenient it is that a patient experiences symptoms of his "disease" when he skips a dose because it reminds him to take his pill. It was almost comical if it wasn't so serious.

Sorry I'm posting for the third time, I only got through 1/3 of the post until I searched around on the 'Net to get that link for you.

I'll read the post on Lexapro in a bit (I've been on that too), but here's my opinion of Effexor:I took Effexor from about Oct. 2006 to Jan. '07. Effexor helped me while I was on it in Oct. and early Nov.; my depression was staved off for the most part. Fast-forward to mid-Nov.: I'm diagnosed as bipolar and basically told that antid's can trigger mania in me so off Effexor I go. I tapered off but whoa, man, was it awful. I guess if you want to know the whole story, you can go here, but I can attest to the fact that Effexor does have its benefits (i.e. weight loss!). The withdrawals are so awful, however, it practically negatives the positive effects, no matter how long a patient has been on it. I've been on Paxil and experienced brief brain shocks then, but the brain shocks I experienced on Paxil were nowhere near the hell that I've experienced on Effexor. I've been off of Effexor for nearly a week now and helped offset the longevity of withdrawal symptoms by using fluoxetine (which had symptoms that were an entirely different matter). Long story short: I cut my withdrawal symptoms down by 90% by using fluoxetine for a few days. I still have brain shocks that linger with me, however.

So, while I can wholeheartedly agree that Effexor's a great drug that staves off depression, I wholeheartedly disagree that Effexor's long-term use is the best course of treatment. (I hope that made sense.)

"10/6/99 PROVIDENCE, R.I. (AP) - The American Psychiatric Association plans to investigate a report that the head of Brown University's psychiatric department failed to disclose more than $500,000 in consulting fees, most from pharmaceutical companies whose health benefits he praised in journals and at conferences.

Dr. Martin Keller, a noted researcher on depression, could be banned from APA-sponsored conferences if he did not follow the group's policies for financial disclosures, association spokeswoman Lynn Writsel said Wednesday.

The Boston Globe reported this week that Keller failed to disclose that he was paid more than $500,000 in consulting fees in 1998.

Most of the money came from pharmaceutical companies whose drugs he praised in medical journals and at the APA's annual meeting this year and last, the newspaper reported.

Keller, of Newton, Mass. could not be reached at his home or office for comment, and did not return messages left at both places.

http://www.freerepublic.com/forum/a392029682a23.htm

If true, it would certainly explain the rather peculiar world according to Martin Keller MD.

HeyIt's only me, this comment made possible by some nifty bit of self promotion by CL Psych via my blog 'www.grahamsblog.com'

lol

You scratch mine yada yada yada. BTW, have added this Post link to my Venlafaxine link list. Hope you are OK with that?

RE this stuff your posting about. So many valid points, so many valid reasoning's...

I got carried away reading all the NEGATIVE press RE withdrawal on forums etc, and it can cloud your judgement, especially if you are a active obeserver only.

I am active participant in this but am thankful for Blogs like this that help put a more 'neutral' spin on the hype, rather than get carried away with the "one sided brigade'.

Ultimately, partly due to the wide availability of information, mostly negative, I made the choice to take myself of Efexor. I weighed up all the options, and considered it the 'better' bet... I'll moan and bitch about the withdrawal symptons, but one hopes it is a relative short blip in time over being well and truely addicted and reliant on them for infinity...

I still got grey matter and substance in my skull, gonna get out now whilst there is still some there.

Overall I am 'happy' with the decision. My family Doc agrees and says that it's a huge thing to actually be 'in control' and not slave to. Even with all the horror stories.

As a psychotherapist who sees that depression is most often the result of what people experience (shame, worthlessness, failure, rejection, loss, etc) and is a method of shutting down these painful feelings, I am totally biased. But I am going to state my view as simply as this: Taking medication to treat depression is like stitching up a bullet wound without taking the bullet out. It never really heals and the wound may fester. Effective psychotherapy, on the other hand, takes the bullet out before stitching up the wound. Therapy helps to heal the underlying wound which fueled the depression. If you’d like to read more about this, I wrote a piece called Therapy & Medication published here: http://www.goodtherapy.org/57.html

Once I stopped my alcoholism and sex addiction, I tried everything from Yoga and exercise, to meditation, St John ’s Wart, Gaba, 5htp, Cognitive Behavioral Therapy and psychotherapy to relieve the symptoms of my Obsessive Compulsive Disorder and Depression. I finally gave in when I nearly had to be hospitalized, loose my job, loose my family and lost my mind (not always a bad thing  ). Effexor has been a God send for me. If I have to take it forever then so be it. Maybe one day I’ll go cold turkey to see if my newer belief systems programmed through therapy and 12 step programs are enough to keep the ‘demons’ at bay so to speak. When/if that day comes, I have no doubts though that I will have to go through quite a lengthy and painful withdrawal before my body reaches its own equilibrium. However, I totally agree with what you guys are saying regarding the mis-informative statements made by these companies. It’s wrong and they should be held accountable for it. The truth will set us all free!

Humming_bird:NEVER cold turkey from Effexor. I repeat, NEVER. It is physically addicting, and requires a long and careful weening process, which has nothing to do with the presence or absence of underlying demons. It's a physical fact. I've experienced it, and so have hundreds of thousands of others. Go off it, by all means, if you wish, but NEVER cold turkey. Ween off it with the supervision of a doctor. Don't use a cold turkey cessation to test whether or not you've slain your dragons, because a) the two phenomena are in no way related and b) the level of physical and emotional discomfort you will certainly experience will erroneously convince you you're still psychologically impaired. Withdrawal is purely a physiological challenge, and should be approached with that in mind. You can test your victory over demons later, against more appropriate life challenges. All the best to you...

I ran out of my effexor and didn't get in any hurry to go get more because I was totally unaware of the withdrawals. Anyway, on the 4th day when I woke up I thought I would die and seriously wanted to! It was horrible! That's when I decided I didn't want to be on that crap for the rest of my life. I only took it regularly for less than 2 months and it took me almost 5 to ween off of it. I am now 3 weeks effexor free and will never touch that sh*t again! You definitely cannot do it cold turkey!

I was on Effexor 150mgs for 8 weeks and decided to quite cold turkey, I kept falling asleep everywhere, even when driving with my Kids. On the third and fourth day, I had projectle vomiting, abd pain, nausea, diarrhea, extreme dizzyness, exhaustion, headaches. I happen to work as an RN in and ER. My co-workers gave me 4 litres of IV fluids, pain and nausea medication. My potassium and blood sugar were so low due to the continuous vomiting, that I had to have them replaced as well. I am now 7 days free of the drug and will never touch it again. I also never knew about the withdrawl side effects prior to starting this medication. I still have some abd pain, headaches, nausea and dizzyness, but feel much better.

For those looking for detail on what to expect during withdrawal, I offer my notes:

I'll let others debate the merits of this drug.

I will simply say that it's understood that big pharmaceutical companies try to improve the return on their investment but expanding the definition of conditions treated by each of their drugs. More patients using a drug means more profit.

This drug may be beneficial to patients suffering from debilitating mental illness that never expect to stop using the drug. But it is not a fit for those of us that expect to stop taking the drug after a period of time. Having experienced the withdrawal, I find it unconscionable that physicians don't think more carefully before prescribing this drug. In fact, I think it should be criminal.

Notes & Lessons Learned- It took a total of 36 days.- I was using the generic extended release version and it came in a small hard pill. I began the process by cutting the small pill in half.- I used a 1/2 pill for 14 days then stepped down to a 1/4 pill for 8 days then stopped taking it altogether.- It took 8-9 days for the symptoms to subside each time I stepped down. Make sure day 6 or 7 of the step down falls on a weekend!- Vertigo was always accompanied by two or three pulses of loud white noise that I could feel as well as hear (referred to by others as brain zaps). The sound could also be described as a muffled hi-hat cymbal. So when you read 'vertigo' in the notes below it was always accompanied by this disturbing noise.- I took Dramamine when the vertigo was at its heaviest based on a post I read from another thread. I can't say that it helped the dizziness but I didn't experience nausea.- Getting a little extra sleep is probably one of the best things you can do for yourself.- I planned the final step down around a trip my wife planned with the children to visit her mother. It relieved a lot of pressure to know that I didn't have to worry about anyone else's feelings while I was battling through this really difficult period.- Day 6 during the first step down was the worst.- Days 12+ were bad because it truly felt like it would never be over and I felt like my emotions were raw. In addition to battling the symptoms I was fighting to keep from hurting others' feelings.

1/2 dose:Day1 surprised not to feel any withdrawal symptoms.Day2 moderate vertigo through afternoon and evening.Day3 heavy morning vertigo, better in the afternoon but extreme fatigue, excellent sleep.Day4 fatigue, head throbbing - not a headache just a throb, minimal vertigo throughout the day and evening.Day5 morning fatigue, felt normal afternoon and evening.Day6 heavy fatigue, flu like symptoms morning through the afternoon, whipped out and didn't want to move, felt better in the evening.Day7 normal all day.Day8 vertigo in the morning, felt normal in the afternoon, heavy fatigue in the evening.Days9-14 normal all day.

1/4 dose:Day1 normal all day.Day2 moderate vertigo in the morning, head throbbing - again no headache just a throb.Day3 moderate vertigo with head throb in the morning.Day4 & 5 normal all day.Day6 heavy vertigo all day and evening.Day7 heavy vertigo all day and evening, flu like feeling in the afternoon.Day8 heavy vertigo and fatigue in the morning, subsided by evening.

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About Me

I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...